Give someone authorisation

Give someone authorisation to arrange your health care matters

Note: on the form, we ask the both of you for an official signature. Without them, we can unfortunately not accept authorisation (power of attorney).

My details

 
 
 (dd-mm-yyyy)  
 
optional
 
   
 
Find your BSN on your driving license or passport
 
Find it on your insurance card or policy document
 

I authorise

 
 
 (dd-mm-yyyy)  
 
optional
 
   
 
Fill in only if you are insured at Zilveren Kruis


 

Authorisation period

Please note! The authorisation is valid up to 5 years.

 (dd-mm-yyyy)  
 (dd-mm-yyyy)  

Signature

 (dd-mm-yyyy)  

Please note! This form is only valid with both signatures. Yours and the person you authorise. Scan or take a digital picture of both signatures. Add that as an attachment. You can only upload .pdf, .jpg, of .png files.

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